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Perioperative Care, Enhanced Recovery After Surgery and Reducing Opioid
Dependency
Session #BP2, February 11, 2019
Julie K Marosky Thacker, MD, Associate Professor of Surgery, Duke Health
Christopher J Vail, PA-C, Director of Clinical Informatics, Duke Surgery, Duke Health
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Julie K. Marosky Thacker, MD
Christopher Vail, PA-C, MMCi
Has no real or apparent conflicts of interest to report.
Conflict of Interest
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• Review paper based start of enhanced recovery
• Communication strategies
• Education strategies
• Patient engagement with apps
• Ordering strategies
• Outcomes
Agenda
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• Illustrate how to enhance care coordination by capturing discrete
data of patient surgical status and sharing across the care
continuum
• Discuss how to leverage pre-visit planning and monitor care plan
compliance to prevent surgical complications
• Discuss how to improve patient education and outcomes through
administering ERAS specific video educational content prior to the
surgical procedure
• Outline the benefits to utilizing standard orders for epidurals
instead of opioids in peri-op process
Learning Objectives
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Paper based project:
Enhanced Recovery Beginnings
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Brief review of the results:
Enhanced Recovery Beginnings
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Began as a CPOE approach
• Standardized orders / order sets
Communicating appropriate patients on protocol difficult
• Information +/- part of nursing handoff
• Information +/- part of provider handoff
• Day of surgery / pre-op holding verbal based
Need for identifying patients early in their surgical journey
became apparent to improve protocol compliance and
improve coordination
• Time sensitive elements of protocol
Enhanced Recovery Transition to EHR
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Patients identified as ERAS during surgical case posting:
Communication Strategies
Improving care
coordination by
capturing discrete data
of patient surgical status
and sharing across the
care continuum.
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Discrete identification allows for signal to be transmitted throughout
the patients many stops
Communication Strategies
Patient ERAS status
evident when in the Pre-
Anesthesia testing.
Helps to ensure that
anesthesia planning is
consistent with ERAS
process.
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Day of Surgery / Pre-Op Holding:
Communication Strategies
Patient ERAS and
Epidural status visually
identified on the
Perioperative Status
board.
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Inpatient Units:
Communication Strategies
ERAS flags continue for
bedside nursing and
rounding physicians to
be alerted to a protocol
patient
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EHR based Care Plans and Education Templates Developed
Education Strategies
• Allows nurse to
adhere to protocol
and truly know what’s
next for the patient
• Reviewing goals met
easy perform at a
glance without in
depth chart reviews
for individual
measures / goals
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Education Templates that span across environments
Education Strategies
• Allows nurses in
multiple settings to
provide appropriate
education to the
patient
• Allows for review /
reinforcement of
topics covered on a
per patient basis
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Process Measures to Track Use of HIT tools:
ERAS for DUH Prostatectomy Go Live September 2017
Education Strategies
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Written materials provided pre-op and reinforced during
hospitalization
• Patients without access to technology
• Multidisciplinary development
iOS application also available to walk patient through pre-
surgery and post-op phases of their recovery
• Videos
• Activity tracker
• More
Patient engagement with apps
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Available on the Apple Store:
Patient engagement with apps
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Pre and post-op information available
Patient engagement with apps
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Trackers for enhanced engagement:
Patient engagement with apps
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Trackers for enhanced engagement:
Patient engagement with apps
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Easy setup and secure data:
Patient engagement with apps
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Introductory videos & ostomy
overview videos:
Patient engagement with apps
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Multimodal pain control key tenant of ERAS strategy
• Reducing opioids a goal across all programs
Analysis in PACU revealed patients receiving high amounts
of opioids despite epidural in place
• Nursing gap in training on education and epidural protocols
• Closed gap and allowed for incorporating into RN practice
Orders required for new protocols and guidance
• New PACU orders available for Anesthesiologist
• By enhancing training for epidurals, other medication
classes were also incorporated into PACU RN practice
(lidocaine drips, etc.)
Ordering strategies in Peri-Op
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Ordering strategies in Peri-Op
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Ordering strategies in Peri-Op
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Aim of most recent Colorectal program updates
• Increase patient experience from start to finish
• Reduce opioid burden
LOS, 30 day readmissions, HCAHPS
• Improvements welcome but not primary focus
Outcomes
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Outcomes
ALOS has dropped from
5 days to 4 days even with LOS
index that is higher than LOS
consistently
Represents a 28% reduction
in ALOS from FY15 to current
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Outcomes
ERAS for Colectomy implemented at
DRH and DRAH in FY17. They saw
a similar reduction from average
readmission rate of 20% down to 5%.
DUHS overall saw a 50% reduction
in readmit rate from FY15 to
current
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Patient flow summary
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Conclusions
Constant iterations needed to utilize the EHR to enhance
the patient experience at each step of the surgical process
• Patient centered process foremost
• Engagement critical
Develop EHR tools for all participants in the patient’s care
(e.g., nursing care plans & education templates)
• Allows for all to practice at top of scope
• Drives engagement across the board
Outcome improvements from all parties being engaged
